American Specialty Pharmacy has 4 Pharmacists on site to help ensure
quality of compounded products.

•

American Specialty Pharmacy has Two “State of the Art” ISO-5 Class-100
clean rooms. One for compounding all sterile preparations & one
negative pressure chemo room for compounding Chemotherapy
medications.

•

American Specialty Pharmacy is
fully compliant with USP797

•

E-Prescribing capability with real
time order entry and tracking
system

•

Specialized Customer Service

•

One stop for all your
Pharmaceutical needs

For all questions or concerns please feel free to call us
any time at (877) 753-6877

PROCEDURES FOR OUT OF TOWN OR
OUT OF STATE CII'S
WHEN DEALING WITH OUT OF TOWN OR OUT OF STATE CII'S
THE CLINIC WILL NEED TO:
• FAX THE HARDCOPY TO THE PHARMACY
• MAIL THE HARDCOPY TO THE PHARMACY IN A PREPAID FED-EX
ENVELOPE PROVIDED BY THE PHARMACY. (THE PRESCRIPTION WILL NOT
BE MAILED TO THE PATIENT UNTIL HARDCOPY IS RECEIVED)
TO THE MARKETERS:
IF YOU HAVE A CLINIC THAT WANTS TO USE US FOR THEIR CII MEDICATIONS
PLEASE CONTACT THE DELIVERY MANAGER AT THE PHARMCY SO HE CAN
PROVIDE YOU WITH THE PREPAID ENVELOPES TO BE GIVEN TO THE CLINIC.
(PLEASE HAVE THE CORRECT ADDRESS FOR THE CLINC READY) PLEASE KEEP
IN MIND WE DO NOT WANT CLINICS TO ONLY USE OUR PHARMACY FOR CII'S,
WE WILL FILL CII'S AS A CURTISY WHEN FILLING OTHER MEDICATIONS FOR
THAT CLINIC. WE DO NOT WANT ONLY CII'S COMING FROM ANY CLINIC.
IF YOU HAVE ANY QUESTIONS PLEASE FEEL FREE TO CONTACT MAJA @ 214478-8564 OR RENEE @ 214-733-0741
DELIVERY MANAGER (HAIDER) 214-919-2090

CONVENIENCE IS
OUR BUSINESS
About Us
• American Specialty Pharmacy is one of the
leading providers of pharmaceu
services in the United States. Our
knowledge and exper
in the business
makes us recognizable in the
industry.
pharmaceu

• At American Specialty Pharmacy, we are

dedicated to address the well-being of our
customers. We are driven by our
commitment to be the best and strive to
bring the best services and solu
to all
our clients.

solu

r all your prescrip

• Our dedicated staﬀ works diligently to
reduce the stress,
put into handling each claim.

Continuation of therapy:
Right knee
Left knee
D a te of la s t tre a tme nt:

both knees

T oday’s date:

Date needed:

CLINICAL INFORMATION - all clinical questions must be completed for precertiﬁcation request.
Requesting prior authorization for viscosupplementation therapy for:
Right knee
Left knee
both knees
Please indicate which drug you are requesting
: (P is preferred, NP is non-preferred)
Euflexxa ® (P)
Hyalgan ® (NP)
Orthovisc ® (P)
Supartz ® (NP)
Synvisc ® (NP)
Synvisc One ® (NP)
Yes
No Does the patient have documented symptomatic osteoarthritis of the knee?
Yes
No Has the patient had a documented failure after at least 3 months of conservative therapy (including physical therapy, pharmacotherapy, i.e.
non steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and/or topical capsaicin cream)?
Yes
No Is the patient unable to tolerate conservative therapy because of adverse side effects?
Yes
No Has the patient failed to adequately respond to aspiration and injection of intra-articular steroids?
Yes
No Does the patient report pain which interferes with functional activities (i.e., ambulation, prolonged standing)?
If Yes, is the pain attributed to other forms of joint disease?
Yes
No
Yes
No Does the patient have any contraindications to the injections (i.e., active joint infection, bleeding disorder)?
Yes
No Has the patient had a documented trial and failure of Euflexxa and Orthovisc?
If Yes, please provide the dates of treatment for both products:
Euflexxa:
Orthovisc:
If requesting additional series of injections for patient: Date of last injection from prior series:
Yes
No Did the patient respond adequately to the prior series of injections?
Yes
No Does the patient’s medical record demonstrate a reduction in the dose of NSAIDs (or other analgesics or anti-inflammatory medication)
during the period following the previous series of injections?
Yes
No Does the patient’s medical record document significant improvement in pain and functional capacity as the result of the previous injections?

Prescriber’s Signature (signature required. NO STAMPS) ____________________________________________________ Date _____________
IMPORTANCE NOTICE: This fax is intended to be delivered only to the named addressee. It contains material that is conﬁdential, privileged, proprietary or exempt from disclosure
under applicable law. If you are not the named addressee, you should not disseminate, distribute, or copy this fax. Please notify the sender immediately if you have received this
document in error and then destroy this document immediately. Medicare and Medicaid or another state funded program will not cover above mentioned compounds. Co-payments due at dispensing of the medication

Fax completed form to (888) 966-0188

Visit us at WWW.AMERICANSPECIALTYPHARMACY.COM for online ﬁllable forms.